C H A P T E R 15
Postoperative Urinary Retention
Yixi Kevin Lu, DPM
INTRODUCTION
Urinary retention is a rare podiatric postoperative
complication, but it still can prolong hospital stays and
increase health care costs. Furthermore, the podiatric
resident is often ill prepared to manage this situation as he
or she begins residency.
In the minds of residents, postoperative urinary
retention (POUR) is usually secondary to postoperative
pain, postoperative nausea and vomiting, and more
serious postoperative complications such as infection, and
deep vein thromboses, if thought of at all. The incidence
of POUR ranges from 5-70%, depending on different
surgical specialties and the respective procedures, as well as
an inconsistent denition of POUR. Universally, it is the
inability to void in the presence of a full bladder. Inability
to void 8 hours after the end of surgery, or after a Foley
catheter is removed is a commonly-used criterion. In
addition, outside the parameter of time, the inability to void
in the presence of >600 cc of urine as seen on bladder scan
is considered urinary retention.
Micturition is the discharge of urine from the bladder.
The normal adult bladder holds about 400-600 cc of urine.
At about 150 cc, the rst urges to void begin, and a sense
of fullness is felt at about 300 cc. The detrusor muscle in
the bladder wall contracts to push urine out of the bladder
through the bladder neck and into the urethra. The bladder
neck sphincter muscle must relax to allow the urine to
pass. When the coordination of these two actions become
deranged, POUR can occur.
RISK FACTORS
Urologic/gynecologic, anorectal, and inguinal procedures
have a greater incidence of POUR compared to podiatric
and orthopedic procedures. Other risk factors of POUR
include anesthetic technique, where general anesthesia
confers a higher risk for POUR than MAC anesthesia, and
spinal and epidural anesthesia confer an even higher risk.
Males are at a higher risk than females, but this is likely due
to many older men having some degree of benign prostatic
hyperplasia (BPH), whether they know it or not. Other
than male sex and older age (>50 years), other risk factors
include previous pelvic surgery, neurological diseases,
and preoperative medications, specically alpha agonists
and beta-blockers. Longer duration of surgery, sedative
medications, and postoperative analgesia can also contribute
to POUR.
DIAGNOSIS, PITFALLS,
AND CONSIDERATIONS
If a patient has not voided 8 hours after surgery or 8 hours
after removal of a Foley catheter, a bladder scan is often
used to determine how much uid is in the bladder. Clinical
examination and questioning is often unreliable. Palpating
for a distended bladder is made difcult by many patients
body habitus. Presence of urgency, distention, and pain
and tenderness is also unreliable because the patient is
often sedated on pain medications. Even a bladder scan can
underestimate the actual amount of urine present because
of body habitus, tissue edema, scarring, and previous
surgery. The most accurate way to determine urine volume
is directly, via straight catheterization and drainage of the
bladder. It is usually a good idea to have the bladder scan
performed again post-void to check for post-void residual
urine. If there is greater than 150 cc, an indwelling Foley
catheter and urology consult should be considered
In the outpatient setting, a bladder scan can be used
because it is quick and noninvasive. In patients with at
least one risk factor, a bladder scan can be performed at 4
hours postoperative, and if >600 cc are present, one time
straight catheterization can be performed, and the patient
can be sent home. Again, a post-void bladder scan to check
for residual volume is a good idea. If there are <600 cc on
the scan, the patient can be sent home without straight
catheterization. Regardless, all patients should be advised to
seek medical attention if after 8 hours they have not voided.
In the inpatient setting, the patient can be straight
catheterized once if after 8 hours he or she has not voided
and a bladder scan shows >600 cc. In some cases, the POUR
will resolve by itself afterwards. If it does not resolve, a
straight catheterization may be performed again, but
straight catheterizations are invasive and are not without
complications. Prostatitis in males, urinary tract infection,
urethral trauma, hematuria, and patient discomfort are
things to consider. More than 2 straight catheterizations
are discouraged, and an indwelling Foley catheter should be
considered in cases of refractory cases of POUR. It should
be pointed out that repeating a bladder scan after a straight
catheterization is a good idea to check for post-void residual
volume. Furthermore, patients with severe BPH, congenital
defects related to the urinary tract, or recent urological
surgery should not be straight catheterized, unless urology
has been consulted. Some patients require a urologist to
place catheters, and some POUR complications may escalate
74 CHAPTER 15
into a patient requiring a suprapubic catheter if traditional
urethral catheters are contraindicated.
Systemic complications of straight catheterization
include transient hypotension, (which can lead to syncope),
and post-obstructive diuresis, (which can lead to dehydration
and electrolyte imbalances). These can be self-limiting the
majority of the time. One should take great care in uid
management in patients with concomitant congestive
heart failure or advanced kidney disease, as uid overload
is potentially life-threatening in this patient population.
Patients with chronic kidney disease should be questioned
to determine if at baseline he or she makes urine, as many
kidney disease patients are oliguric, and end-stage kidney
disease patients are anuric.
These complications of straight catheterization are more
pertinent to the podiatric resident than those of the actual
urinary retention. Most commonly, urinary tract infection,
pyelonephritis, kidney injury, and physical bladder damage
can occur from unresolved urinary retention, but the
management of these should be deferred to the hospitalist,
infectious disease specialists, and/or the urologist. Inserting
a Foley catheter until urology can assess the patient is
prudent. Usually POUR is self-limiting, but a urology
consult is a must if the patient has to be sent home with
an indwelling Foley catheter because of persistent POUR.
These patients will need follow up with outpatient urology.
A misguided notion beginning residents may consider
is increasing the intravenous (IV) uids for the patient.
However, POUR is not an issue of the kidneys making urine,
but of urine leaving the bladder. If IV uids are increased
in the setting of urinary retention, the bladder will become
more distended. With increasing distention, the muscarinic
receptors in the smooth muscle bladder wall become less
concentrated as the bladder wall stretches. This effect of
reduced concentration of receptors inhibits the detrusor
muscle function. The ability of the bladder to contract is
then diminished. Even when straight catheterization allows
the bladder size and receptor concentration to return to
normal, normal micturition is not always restored. Normal
function will return more slowly in these cases.
PROPHYLAXIS AND TREATMENT
There are no prophylactic guidelines for POUR in
orthopedic/podiatric surgery, given the incidence is so low.
Tamsulosin has been studied in pelvic/anorectal surgeries.
Madani et al gave 0.4 mg of Tamsulosin 14 and 2 hours
before surgery, and 10 hours after (2). This yielded a 5.9%
incidence of POUR versus 21.1% in their control group.
Mohammadi-Fallah et al (3) had similar results giving 0.4
mg 6 hours before and 6-12 hours after surgery, witnessing
a drop from 15% to 2.5% in POUR.
Another alpha blocker, prazosin, has been investigated,
where 1 mg was given 12 hours before surgery, and again
12-24 hours after surgery. Gonollu et al (4) found a decrease
from 25% to 10.8% in POUR incidence. It should be noted
that although medications like tamsulosin are primarily used
for male BPH/hypertrophy, they still can be used in female
patients experiencing POUR. Bethanachol, a muscarinic
agonist, can also be administered in the face of POUR. As
mentioned above, if there is no medical response, the patient
is typically sent home with an indwelling Foley catheter or
taught how to straight catheterize themselves, with close
urology outpatient follow up.
CONCLUSION
The important questions to ask in male, and even female
patients undergoing longer, more complex surgery under
general anesthesia are whether they have experienced
POUR in the past and about previous surgical history,
especially pelvic/anorectal surgeries. In these patients, the
likelihood of experiencing POUR again is high, and it may
be worthwhile to prophylax, as described in these studies.
At a minimum, one can administer one of these medications
once POUR has been encountered.
Lastly, other considerations include patient position
when trying to void, warm compresses, and the environment.
Many older male patients have family members or friends in
the room, and it could be helpful to give the patient some
privacy. Some component of POUR could be volitional.
Usually, the patients surgical extremity is elevated and
male patients trying to use the bedside urinal while laying
down may be difcult and hinder the conscious aspect of
voiding. Warm compresses to the suprapubic area have been
described to help in nursing textbooks, although there are
no studies to corroborate this. However, it is worth a try, as
it is easy, inexpensive, and if you as a surgeon can save your
patient from the unpleasant experience of getting a straight
catheter, it will make a difference to your patient and his or
her experience.
REFERENCES
1. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary
retention: anesthetic and perioperative considerations.
Anesthesiology 2009;110:1139-57.
2. Madani AH, Aval HB, Mokhtari G, Nasseh H, Esmaeili S, Shakiba M
et al. Effectiveness of Tamsulosin in prevention of post-operative
urinary retention: a randomized double-blind placebo-controlled
study. Int Braz J Urol 2014;40:30-6.
3. Mohammadi-Fallah M, Hamedanchi S, Tayyebi-Azar A. Preventive
effect of tamsulosin on postoperative urinary retention.Korean J
Urol 2012;53:419-23.
4. Gonullu NN, Dulger M, Utkan NZ, Canturk NZ, AlponatA.
Prevention of postherniorrhapy urinary retention with prazosin.
Am Surg 1999;65:55-8.